Is the ATLS classification of hypovolaemic shock appreciated in daily trauma care? An online-survey among 383 ATLS course directors and instructors.

OBJECTIVE: For the early recognition and management of hypovolaemic shock, ATLS suggests four shock classes based upon an estimated blood loss in percent. The aim of this study was to assess the confidence and acceptance of the ATLS classification of hypovolaemic shock among ATLS course directors and instructors in daily trauma care. METHODS: During a 2-month period, ATLS course directors and instructors from the ATLS region XV (Europe) were invited to participate in an online survey comprising 15 questions. RESULTS: A total of 383 responses were received. Ninety-eight percent declared that they would follow the 'A, B, C, D, E' approach by ATLS in daily trauma care. However, only 48% assessed 'C-Circulation' according to the ATLS classification of hypovolaemic shock. One out of four respondents estimated that in daily clinical routine, less than 50% of all trauma patients can be classified according to the current ATLS classification of hypovolaemic shock. Additionally, only 10.9% considered the ATLS classification of hypovolaemic shock as a 'good guide' for fluid resuscitation and blood product transfusion, whereas 45.1% stated that this classification only 'may help' or has 'no impact' to guide resuscitation strategies. CONCLUSIONS: Although the 'A, B, C, D, E' approach according to ATLS is widely implemented in daily trauma care, the use of the ATLS classification of hypovolaemic shock in daily practice is limited. Together with previous analyses, this study supports the need for a critical reassessment of the current ATLS classification of hypovolaemic shock.

The ATLS(®) classification of hypovolaemic shock: a well established teaching tool on the edge?

Uncontrolled bleeding is the leading cause of shock in trauma patients and delays in recognition and treatment have been linked to adverse outcomes. For prompt detection and management of hypovolaemic shock, ATLS(®) suggests four shock classes based upon vital signs and an estimated blood loss in percent. Although this classification has been widely implemented over the past decades, there is still no clear prospective evidence to fully support this classification. In contrast, it has recently been shown that this classification may be associated with substantial deficits. A retrospective analysis of data derived from the TraumaRegister DGU(®) indicated that only 9.3% of all trauma patients could be allocated into one of the ATLS(®) shock classes when a combination of the three vital signs heart rate, systolic blood pressure and Glasgow Coma Scale was assessed. Consequently, more than 90% of all trauma patients could not be classified according to the ATLS(®) classification of hypovolaemic shock. Further analyses including also data from the UK-based TARN registry suggested that ATLS(®) may overestimate the degree of tachycardia associated with hypotension and underestimate mental disability in the presence of hypovolaemic shock. This finding was independent from pre-hospital treatment as well as from the presence or absence of a severe traumatic brain injury. Interestingly, even the underlying trauma mechanism (blunt or penetrating) had no influence on the number of patients who could be allocated adequately. Considering these potential deficits associated with the ATLS(®) classification of hypovolaemic shock, an online survey among 383 European ATLS(®) course instructors and directors was performed to assess the actual appreciation and confidence in this tool during daily clinical trauma care. Interestingly, less than half (48%) of all respondents declared that they would assess a potential circulatory depletion within the primary survey according to the ATLS(®) classification of hypovolaemic shock. Based on these observations, a critical reappraisal of the current ATLS(®) classification of hypovolaemic seems warranted.

Trauma scoring systems and databases.

This review considers current trauma scoring systems and databases and their relevance to improving patient care. Single physiological measures such as systolic arterial pressure have limited ability to diagnose severe trauma by reflecting raised intracranial pressure, or significant haemorrhage. The Glasgow coma score has the greatest prognostic value in head-injured and other trauma patients. Trauma triage tools and imaging decision rules-using combinations of physiological cut-off measures with mechanism of injury and other categorical variables-bring both increased sophistication and increased complexity. It is important for clinicians and managers to be aware of the diagnostic properties (over- and under-triage rates) of any triage tool or decision rule used in their trauma system. Trauma registries are able to collate definitive injury descriptors and use survival prediction models to guide trauma system governance, through individual patient review and case-mix-adjusted benchmarking of hospital and network performance with robust outlier identification. Interrupted time series allow observation in the changes in care processes and outcomes at national level, which can feed back into clinical quality-based commissioning of healthcare. Registry data are also a valuable resource for trauma epidemiological and comparative effectiveness research studies.

A critical reappraisal of the ATLS classification of hypovolaemic shock: does it really reflect clinical reality?

AIM: The aim of this study was to validate the classification of hypovolaemic shock given by the Advanced Trauma Life Support (ATLS). METHODS: Patients derived from the TraumaRegister DGU(®) database between 2002 and 2010 were analyzed. First, patients were allocated into the four classes of hypovolaemic shock by matching the combination of heart rate (HR), systolic blood pressure (SBP) and Glasgow Coma Scale (GCS) according to ATLS. Second, patients were classified by only one parameter (HR, SBP or GCS) according to the ATLS classification and the corresponding changes of the remaining two parameters were assessed within these four groups. Analyses of demographic, injury and therapy characteristics were performed as well. RESULTS: 36,504 patients were identified for further analysis. Only 3411 patients (9.3%) could be adequately classified according to ATLS, whereas 33,093 did not match the combination of all three criteria given by ATLS. When patients were grouped by HR, there was only a slight reduction of SBP associated with tachycardia. The median GCS declined from 12 to 3. When grouped by SBP, GCS dropped from 13 to 3 while there was no relevant tachycardia observed in any group. Patients with a GCS=15 presented normotensive and with a HR of 88/min, whereas patients with a GCS<12 showed a slight reduced SBP of 117mmHg and HR was unaltered. CONCLUSION: This study indicates that the ATLS classification of hypovolaemic shock does not seem to reflect clinical reality accurately.